Healthcare Provider Details

I. General information

NPI: 1952402893
Provider Name (Legal Business Name): KRISTINE CORLISS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56-117 PUALALEA ST
KAHUKU HI
96731-2052
US

IV. Provider business mailing address

56-117 PUALALEA ST
KAHUKU HI
96731-2052
US

V. Phone/Fax

Practice location:
  • Phone: 808-293-9221
  • Fax: 808-293-2262
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPH-654
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number30344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: